PROBATE COURT OF _ _ _ _ _ _ COUNTY, OHIO INRE:CHANGEOFNAMEOF____________~--~~----------------(Present Nllme) TO ______________________~-=--~__--------------------- CASE NO, _________________ (Name Requested) APPLICATION FOR CHANGE OF NAME OF MINOR [R.C.2717.01] The applicant states that the applicant is the parent that the minor has been a bona fide resident of year immediately prior to the filing of this application. 0 0 legal guardian 0 guardian ad litem of the minor and County. Ohio, for at least one A certified copy of the minor's birth certificate is attached. o The applicant states that the name and address of the mother of the minor is: Name City State Zip o and the name and address ofthe father or alleged father of the minor is: Name Address City State Zip o Applicant states that the address of the reasonable diligence be ascertained. 0 mother 0 father or alleged father is unknown and cannot with o There is no person alleged to be the father of the minor. The applicant states that the person for whom a change of name is being requested 1} _ _ 0 has 0 has not been convicted of, pleaded guilty to, or been adjudicated a delinquent child for initials identity fraud. 2) _ _ initials 0 has a 0 has no duty to comply with R.C. 2950.04 or R.C. 2950.041 because the applicant was convicted of, pled guilty to, or was adjudicated a delinquent child for having committed a sexually oriented offense or a child-victim oriented offense. FORM 21.2 - APPLICATION FOR CHANGE OF NAME OF MINOR Amended: January 1,2013 Discard all previous veQlons of this form American LegalNet, Inc. www.FormsWorkFlow.com {Revel'lMl of Form 21.2) CASE NO._ _ _ __ o The applicant requests a change of name of the minor from _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ to~~~~----------------------------------------------for the following reason: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ The applicant states that the applicant will cause notice of the application to be published once in a newspaper of general circulation in this county at least thirty (30) days before the hearing on this application. In addition, notice will be given by the applicant to any non-consenting parent or alleged father, whose addresses are known, by certified mail, return receipt requested. Attomey for Applicant Typed or Printed Name Address State Zip Applicanfs Signature Typed or Printed Name Address City City State Zip Telephone Number (include area code) Attomey Registration No. _________ Telephone Number (include area code) JOURNAL ENTRY SETnNG HEARING AND ORDERING NOnCE The Court orders this application set for hearing on the day of " at -:-:---:-_ o'clock __.m. The applicant is ordered to cause notice of the application to be given by one publication in a newspaper of general circulation in this county at least thirty (30) days prior to the hearing date, as well as certified mail service, return receipt requested, if necessary, as required by law. Probate Judge By: Deputy Clerk FORM 21.2 - APPUCATION FOR CHANC3E OF NAME OF MINOR PAGE 2 ~:January1.2013 DllCard all previous venions of this form American LegalNet, Inc. www.FormsWorkFlow.com